Approach Considerations
Treatment of focal impaired awareness seizures may involve pharmacologic therapy and, in certain cases, epilepsy surgery. [8, 9, 10, 11, 12, 13, 14, 15, 16, 17] Special considerations apply to women with childbearing potential.
Anticonvulsant Therapy
There is no clear answer to the question of whether or not to treat after a single seizure. The risk of recurrent seizures is unchanged whether antiepileptic drugs are initiated after the first seizure or after the second. Attention to electroencephalographic (EEG) abnormalities, in addition to discussion with the patient and family, should be part of the decision-making process. In contrast, treatment with antiepileptic medication should always be initiated once a diagnosis of epilepsy is made.
All current antiepileptic drugs (AEDs), with the exception of ethosuximide, can be used in the treatment of complex partial seizures. The choice of an AED should be guided by certain general principles. The best-tolerated AED should be selected for the patient on the basis of side effects and drug interactions. Monotherapy is always initially preferred over polytherapy for treating seizures. High dosages of a single agent may be required to achieve seizure control before adding a second agent.
Treatment side effects
Side effects are common with all antiepileptic drugs. [27] All AEDs are central nervous system (CNS) depressants and therefore may cause sedation, dizziness, and changes in cognition. This side effect is more common in older AEDs. Certain medications may offer favorable side effects (eg, topiramate and weight loss), whereas other medications may be chosen solely on the basis of their route of excretion (eg, levetiracetam and renal excretion). Some side effects may treat comorbidities (eg, gabapentin and certain pain syndromes).
Certain AEDs have specific toxicities (eg, hepatic failure or bone marrow suppression) that necessitate periodic blood monitoring. Patients should also be educated about how to recognize the signs of a severe adverse drug reaction.
AED therapy can be continued in the face of mild elevations of transaminase levels and mild depressions of blood cell counts because these findings do not indicate pending hepatic failure or aplastic anemia.
Considerations in women
Women of childbearing age should be educated regarding the drug interactions between AEDs and contraceptive therapy. Women who become pregnant and have a history of seizures should be continued on current antiepileptic drug therapy that controls seizures and not switched to a secondary agent simply because of pregnancy.
Teratogenicity is possible with all AEDs. Most have the potential to cause minor anomalies (eg, fetal anticonvulsant syndrome). Major anomalies (eg, cardiac defects, cleft lip and palate, microcephaly, developmental delay, and neural tube defects) are more common with valproate therapy, especially at high dosages. AEDs impair folic acid metabolism, increasing the risk of NTDs, requiring initiation of folic acid supplementation for all women of childbearing age at a minimum dose of 0.4 mg/day; however, higher doses between 2-5 mg/day are encouraged.
Clinicians should document in writing that they have advised every woman of childbearing potential of the risks and benefits of anticonvulsant therapy, including the increased risk of congenital malformations. [28, 29, 30, 31] Patients should be initiated on folic acid supplementation. Clinicians should also document they have advised women of childbearing age on the risk of oral contraceptive failure that may occur with hepatic enzyme–inducing anticonvulsants.
For more information, see Women's Health and Epilepsy.
Bone health
Long-term anticonvulsant therapy with hepatic enzyme-inducing anticonvulsants also increases the risk for osteoporosis. Patients should undergo bone-density measurements every 2 years.
Monitoring
Anticonvulsant drug-level monitoring may be needed. [32] Consider drug-level monitoring when noncompliance is suspected, in patients at high risk for life-threatening adverse drug reactions, or in patients with mental impairments that limit their ability to communicate.
Anticonvulsant withdrawal
No strict criteria exist as to when anticonvulsant withdrawal is appropriate. [33] Patients who have been seizure free for at least 6 months may undergo consideration in discussion with their physician.
Surgical Treatment of Epilepsy
Epilepsy surgery is indicated for patients who have frequent, disabling seizures despite adequate trials of 2 or more anticonvulsants. Video EEG should be used before surgical referral to qualify events, assess severity, and aid in localization. Surgical procedures include temporal lobectomy, extratemporal resections, corpus callosotomy, placement of a vagus nerve stimulator, hemispherectomy, and multiple subpial transection.
Modification of Activity
All persons with uncontrolled seizures must be advised to refrain from high-risk activities that put themselves or others in danger in the event of a seizure. These activities include, but are not limited to, the following:
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Operating a motor vehicle
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Operating a stove or other dangerous machinery
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Working at heights
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Swimming in open/large bodies of water alone
Clinicians should document in writing that they have advised the patient not to operate a motor vehicle or dangerous machinery or to perform activities that would put the patient or others at risk of injury from a seizure. Persons with uncontrolled epilepsy should be advised to contact the appropriate state agency regarding driving regulations. Some states require physician reporting of drivers who experience seizures.
These activity restrictions should be reviewed in detail (and documented in the medical record) with the patient, family, and/or caregivers.
Consultations
Refer the patient to an epilepsy specialist if the patient has seizures despite previous trials with 2 or 3 anticonvulsants. Consultation with such a specialist is indicated if the patient is a possible candidate for epilepsy surgery.
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Note oral and hand automatisms at initiation of event. Patient is not following commands or answering questions during the event.
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Left temporal sharp wave.
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Left temporal lobe seizure.
